Is It a Hemorrhoid or an Anal Fissure? How to Tell the Difference

Anal fissures and hemorrhoids are two common causes of bleeding from your rectum. If you’re experiencing this symptom, you may be wondering if one of these conditions is the cause. But it can be tough to tell the difference. And the uncertainty of what’s causing the bleeding can be stressful. Here, we discuss some ways you can tell them apart — including the causes, symptoms, and appearance — and how both are treated.

What are anal fissures?

Anal fissures are tears in the skin around a person’s anal canal (the last part of your intestine). They’re pretty common — about 1 in 10 people develop an anal fissure at some point in their lives. People between the ages of 15 and 40 are more likely to get them.

Most often, they’re found right near the anus. It’s possible to develop an anal fissure slightly higher up in the anal canal, near where the digestive tract ends. But this is less common.

Anal fissures can be divided into two categories:

• Acute: This type goes away before 6 weeks.

• Chronic: This type of anal fissures lasts longer than 6 weeks.

Anal fissures can last a pretty long time, and take several weeks to heal.

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What are hemorrhoids?

Hemorrhoids are swollen veins around your anus and/or rectum. The swelling causes inflammation and sometimes pain. And it’s common for the engorged vein to bleed, particularly during passage of a bowel movement. Hemorrhoids are more common than anal fissures — anywhere between 50% and 85% of people have them. They can affect people of all ages, but are a little more common as people get older.

There are two different types of hemorrhoids:

• External hemorrhoids develop right at the end of the anus. They are easy to feel with your finger. And you can usually see them easily, too.

• Internal hemorrhoids develop further up inside the rectum, the last part of the intestine right before the anus. Sometimes, they grow large enough to poke outside of the anus. 

Anal fissures vs. hemorrhoids: Key differences

There’s a lot of overlap between hemorrhoids and anal fissures. Below, we highlight the similarities and key differences between the two.

Causes

Anything that causes irritation or strain around the anus can lead to an anal fissure or hemorrhoids. These common causes include:

• Constipation

• Chronic straining or “bearing down,” which happens with constipation. It can also happen when a person is doing repeated heavy lifting.

• Frequent diarrhea

• Childbirth

The following causes are more likely to increase the chances of developing anal fissures:

• Sexually transmitted infections (STIs) like syphilis, herpes, and HIV (human immunodeficiency virus) can infect the tissues around the anus, making them weaker.

• Inflammatory bowel disease (IBD), such as Crohn’s disease, can cause inflammation in a person’s anal canal, making the tissue more likely to tear. It’s less common for a person with ulcerative colitis to develop an anal fissure. 

• Prior anal surgery may damage and weaken the tissue in the area.

• Anal sex can stretch and weaken the tissue and skin around the anus.

The following causes are more likely to increase the chances of developing hemorrhoids: 

• Sitting for long periods of time, since this increases the pressure on the tissues and blood vessels around the anus.

• Age may also play a role. This is likely related to the way the tissue and blood vessels around a person’s anus naturally gets weaker as they age.

Appearance 

Appearance is one of the more helpful ways to tell the difference between hemorrhoids and anal fissures. 

External hemorrhoids are the easiest to see. They look like swollen lumps around the rim of the anus, and most of the time feel fleshy. Sometimes external hemorrhoids are the same color as a person’s skin. They can also appear blue or purple in color. And sometimes they are red, which can happen if they become irritated.

Internal hemorrhoids are not visible to the naked eye — unless they are large enough that they poke out of the anus. If they do poke out, they may resemble small blue or purple grapes. 

Anal fissures aren’t always easy to see — especially if they are just inside a person’s anal canal. When one develops around a person’s anus, it can resemble a straight line cut, almost like a paper cut. If the skin along each side of the fissure is gently pulled apart, it can look more oval shaped. If it’s chronic, the skin around the edges of the fissure may raise up and feel bumpy.

Symptoms

The symptoms of hemorrhoids and anal fissures are very similar. They both commonly cause:

• Bleeding: You may see bright red blood in your poop, in the toilet, or on the toilet paper after wiping.

• Pain: The pain from both conditions is generally worse when pooping. But both can be uncomfortable even when you aren’t pooping.

• Itching: Either one may lead to itchiness around your anus.

There are fewer differences when it comes to symptoms. Hemorrhoids can make it feel like you still need to poop when you don’t. And internal hemorrhoids are a little different in that they generally don’t cause any pain, unless they’ve started to poke outside of the rectum.

Treatment

Treating either anal fissure or hemorrhoids depends on a few different factors like:

• Severity

• Size

• Duration

• How bothersome it is

Acute anal fissures most often go away on their own without doing anything. And sometimes hemorrhoids are small enough that they don’t need treatment either. 

But if either is causing you discomfort, there are a few things you can try at home:

• Stay well hydrated so that your poop stays soft.

• Stay active to keep your digestive tract moving. 

• Add fiber to your diet, helping you stool more easily.

• Take stool softeners to help prevent straining.

• Take sitz baths to increase circulation to your anus and rectum.

In addition to the above steps, hemorrhoids may also benefit from:

• Hemorrhoid creams, which contain different ingredients to decrease pain and inflammation, and protect the surrounding skin. These can typically be found at any pharmacy. 

• Witch hazel, which contains antioxidants and decreases inflammation. It’s typically sold at pharmacies in liquid, cream, or as wipes.

For larger hemorrhoids that are painful and bothersome, there are a few additional options that can be done in a doctor’s office or surgical setting:

• Rubber band ligation: This is also called “banding.” A rubber band is used to cut off the blood supply to the hemorrhoid. It’s a common approach for internal hemorrhoids.

• Sclerotherapy: This approach similarly cuts off the blood supply to the hemorrhoids. Instead of using a band, it uses medication. 

• Infrared coagulation: This too cuts off the blood supply to the hemorrhoids. But instead of a band or a medicine, it uses an infrared-heated device.

• Surgery: Surgery to remove hemorrhoids is another option. Sometimes this is referred to as hemorrhoidectomy.

Chronic anal fissures — or ones that don’t get better on their own — are treated with:

• Topical medication: These include creams and gels like nifedipine or nitroglycerin, which relax the blood vessels around the anus. This increases blood flow to the area, which helps it heal faster.

• Oral medication: If topical treatments don’t work, oral nifedipine or diltiazem may help. They also relax blood vessels in the area.

• Botulinum toxin injection: Often referred to as botox, this relaxes the muscles around the fissure to relieve pain and help it heal. It’s an option if topical and oral medications don’t work.

• Surgery: Different types of surgery include sphincterotomy, fissurectomy, and anal advancement flap. In a sphincterotomy, a surgeon cuts the sphincter muscle around the anus to help it relax. A fissurectomy cuts out the fissure. And in a flap procedure, a surgeon sews healthy nearby tissue to the fissure to help it heal.

To help keep things clear, we’ve summarized the key similarities and differences between anal fissures and hemorrhoids in the table below.

Will anal fissures and hemorrhoids go away on their own?

For anal fissures and hemorrhoids that are small and not causing any symptoms, it’s likely that they will go away on their own. But if they don’t go away after 7 days and/or you experience any of the following symptoms, you’ll want to see your healthcare professional:

• Fever

• Large amounts of blood coming from your rectum

• Significant pain in your belly or near your rectum

• Lightheadedness

• Dizziness

• Passing out

• Losing weight without trying to

All of these symptoms can be a sign that something more serious is going on, like significant blood loss, an infection, IBD, or cancer.

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Written by:

Cherilyn Davis, MD

Cherilyn Davis, MD, is a board-certified pediatrician in New York City. She has held local and national roles at the American Medical Women’s Association including board member of the physician division and physician chair of social media.

Edited by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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